Morris View Healthcare Center

Complaint #s: NJ00176773 Based on observation, interview, and review of medical records on 10/23/24, it was determined that the facility failed to ensure Licensed Registered Nurse (LPN) #1 followed: a) a physician order for a mist humidifier (a device that adds moisture to the air by releasing a fine mist or vapor) for a resident (Resident #1), b) acceptable standards of nursing practice when LPN #1 signed and initialed [indicating it was administered] on the above mentioned order in Resident #1's electronic Medication Administration Record (eMAR) while the order was not carried out. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of pertinent facility documents it was determined that the facility failed to a.) to maintain proper kitchen sanitation practices in a manner to prevent food borne illness, and b.) discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/08/24 at 9:34 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The juice dispenser machine which was attached to several large juice boxes to be dispensed included: -An Unsweetened black iced tea juice box had a manufacturing label with a Best if Used by date of 5/20/2024. -A Cranberry Juice Fusion juice box had a manufacturing label with a Best if Used by date of 11/28/2023. -A thickened water nectar consistency juice box with a manufacturing label with a Best if Used by date of 4/19/2024. The FSD acknowledged the boxes should have been disposed of and could not explain why they were still in use. The boxes were disposed. 2. Dietary Aide (DA) #1 wearing drop earrings hanging…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure a.) license verification was checked for three (3) out of seven (7) licensed staff (Staff #1, #3, and #6) b.) criminal background check done for one (1) out of 10 staff (Staff #10) and c.) obtain current and past-employer reference checks for six (6) out of 10 staff (Staff #1, #3, #7, #8, #9, #10). This deficient practice was evidenced by the following: 1. On 7/17/24 at 9:00 AM, two surveyors reviewed ten randomly selected facility employee files and revealed the following: A review of Staff #1 (S#1), the Certified Nursing Assistant (CNA), hired 02/06/24. S#1 file did not have a New Jersey Division Consumer Affairs (NJDCA) license verification printout or the copy of the license. There was no evidence of reference checks from past employers in the file. Review of S#3, the Licensed Practical Nurse (LPN), hired 02/16/23. There was no evidence of the reference checks from past…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined that the facility failed to ensure that a.) the residents' Attending Physician signed and dated monthly physician orders for residents under their care for one (1) of 38 residents (Resident #466) reviewed for physician order and b.) the residents Attending Physician visited and documented monthly visits or alternately visited every other month when the Advanced Practice Nurse visited on the subsequent month for five (5) of 38 residents (Resident #18, #80, #227, #257, and #466), reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 7/09/24 at 12:44 PM, the surveyor reviewed Resident #18's electronic medical record (EMR) which revealed that the resident's Attending Physician (AP) did not document any visit for March, April, May or June 2024. The Advanced Practice Nurse (APN), covering for the AP, documented an April and June 2024 monthly visit. There was not a documented AP visit for Resident #18 for the last four months and there was no visit by the APN or AP for May. 2. On 7/10/24 at 12:08…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on observation, interview, and review of medical records and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene practices during dining observation for one (1) of three (3) dining rooms, and for one (1) of two (2) staff (Housekeeper #1 [HK#1]) and b.) follow transmission-based precautions (TBP) to prevent the potential spread of infection for two (2) of two (2) residents (Residents #41 and #111) and not utilizing personal protective equipment (PPE) for a resident on contact precautions for two (2) of two (2) staff (Attending Physician and HK#2) reviewed for TBP, in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for a.) one (1) of three (3) residents' rooms (Resident #32) and b.) two (2) of two (2) common rooms (toilet and chapel room) This deficient practice was evidenced by the following: 1. On 7/15/24 at 10:09 AM, the surveyor met and interviewed Resident#83. The resident requested the follow-up personal meeting after the resident council meeting with another surveyor on 7/10/24. The resident discussed the 1 A/B public toilet room safety railing was loose which Resident #83 had previously reported to the Housekeeping Director (HD) and the Licensed Nursing Home Administrator (LNHA) via email. The resident further stated that the 1 A/B public toilet room was being used by residents. On that same date and time, the resident also mentioned the chapel where residents gather for religious services had an incident/accident a month ago with one resident (Resident #35) who had a cut on their foot and blood was all over the carpet of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that residents were served their meals in a dignified manner during meal service. This deficient practice was observed for one (1) of five (5) residents (Resident #105), in one (1) of three (3) dining rooms. The deficient practice was evidenced by the following: On 7/08/24 at 11:40 AM, the surveyor observed the lunch food truck parked in front of the nursing station of 3D unit. The Concierge staff took the lunch truck into the Dining room wherein there were five residents inside the room. At that time, the surveyor observed the Certified Nursing Aide (CNA) enter the 3D dining room and five residents were served lunch trays except for Resident #105. Resident #105 was seated at one table where there were two other residents. On 7/08/24 at 11:45 AM, the surveyor observed in the 3D unit dining area during mealtime the Registered Nurse (RN) came to the dining room. The surveyor asked the RN why Resident #105 had no lunch tray and was not being served at the same time as the other two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the interview and record review, it was determined that the facility failed to complete the Comprehensive Assessment in accordance with the Resident Assessment Instrument (RAI) for three (3) of 39 residents reviewed for comprehensive assessments (Residents #6, #14, and #135). This deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) RAI Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the Minimum Data Set (MDS). The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after admission to the facility and not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. The MDS completion date for an annual assessment must be no later than 14 days after the ARD (ARD + 14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for two (2) of two (2) residents, Resident #6 and #135, system selected for MDS over 120 days and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS (QMDS) was within 92 days after the ARD of the previous MDS and; 2). the completion date was no later than 14 days after the ARD. 1. Resident #6's ARD was on 11/23/23, the quarterly assessment was not completed until 12/12/23, 19 days later, and was submitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

REPEAT DEFICIENCY Based on the interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately code the Minimum Data Set (MDS) for three (3) of the 38 residents reviewed, Residents #135, #138, and #198. This deficient practice was evidenced by the following: 1. The surveyor reviewed the system selected resident for MDS discrepancy and revealed the following: The admission Record (AR, an admission summary) showed that the resident was admitted to the facility with the diagnosis that included but was not limited to inclusion of body myositis (an inflammatory condition of the muscles that causes weakness), adjustment disorder with depressed mood, ulcerative colitis (a chronic, inflammatory bowel disease that causes inflammation in the digestive tract), and functional quadriplegia (complete immobility due to severe disability or frailty caused by another medical condition). A review of Resident#135's Quarterly MDS (QMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint: NJ#169038 Based on the interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) follow the physician's orders for one (1) of 38 residents, Resident #106, with regard to medications with parameters, and b.) specify a site for a pain medication patch for one (1) of one (1) resident, Resident #316 reviewed for pain management according to standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the interview, record review, and review of pertinent documents it was determined that the facility failed to ensure a resident was provided with an accurate discharge summary at the time of discharge, including a documented medication reconciliation, post-discharge instructions, and physician's prescription per the facility policy. The deficient practice occurred for one (1) of one (1) closed records reviewed (Resident #106) for appropriate discharge. This deficient practice was evidenced by the following: On 7/09/24 at 11:10 AM, the surveyor reviewed the closed medical records of Resident #106 and revealed the following: Resident #106's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to cellulitis (a serious deep infection of the skin caused by bacteria) of the right lower limb, hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone) unspecified, major depressive disorder recurrent unspecified, unspecified sequelae of other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure a.) that the unwitnessed fall investigation included a conclusion for root cause analysis and b.) a new non pharmacological intervention was implemented after each fall for one (1) of three (3) residents reviewed for falls (Resident #227) according to standards of clinical practice and facility's policy and procedure. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

REPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order, b.) ensure respiratory tubing, cannula, and masks were stored properly. This deficient practice was identified for two (2) of two (2) residents (Residents #111 and #466) reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure the daily posting of licensed nurses, certified nursing aide staffing, and the resident census on three (3) of 10 days during the survey. This deficient practice was evidenced by the following: On Monday, 7/08/24 at 9:00 AM, upon entry into the facility, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) which was posted in the reception area of the lobby. The NHRCSR posted for day shift was dated 7/07/24. There was no NHRSCR posted for 7/08/24 day shift. On Tuesday, 7/09/24 at 8:40 AM, the surveyor observed the NHRCSR posted in the lobby. The NHRCSR posted for day shift was dated 7/08/24. There was no NHRSCR posted for the 7/09/24 day shift. On Friday, 7/12/24 at 8:55 AM, the surveyor observed the NHRCSR that was posted in the reception area of the lobby. There was an NHRCSR dated 7/10/24 for the evening shift, 7/10/24 for the night shift, and 7/11/24 for the day shift. There was no NHRCSR posted for the 7/12/24 day shift. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that medications were stored securely and appropriately. This deficient practice was identified in one (1) of three (3) medication carts observed during the medication pass observation. This deficient practice was evidenced by the following: On 7/10/24 at 9:03 AM, the surveyor observed the medication (med) nurse assigned to the South Side of the 2A Unit (med RN) prepare and administer medications (meds) to an unsampled resident. The surveyor observed the med RN remove the resident's med cards (packaging that contains individual doses of med in a numbered plastic blister) and place them on top of the med cart. The surveyor observed the med RN remove the ordered meds from the med cards for administration to the resident, verify the med, then return the med card to the cart after removing a dose. The surveyor observed the med RN return the med cards that had doses removed to the med cart and then lock the cart. On that same date and time, the surveyor observed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NJ#00163219, NJ# 00164434 Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to provide a discharged resident a requested copy of their medical records. This deficient practice was identified for 1 of 2 residents (Resident #1) reviewed for medical record requests. This deficient practice was evidenced by the following: According to the admission record, Resident #1 was admitted to the facility in December of 2022, with diagnoses which included but were not limited to: Myasthenia Gravis (weakness and rapid fatigue of muscles under voluntary control) and Anxiety. According to the Minimum Data Set (MDS), an assessment tool dated 12/28/2022, indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was cognitively intact. Review of the facility provided Release Authorization Information from Medical Records form revealed that Resident #1 and their daughter signed the request form on 1/27/23. On 9/11/23 at 12:34 PM, the Licensed Nursing Home Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint # NJ00161074 Based on observations, interviews, and review of pertinent facility documentation, it was identified that the facility failed to provide a sanitary and homelike environment on 1 of 6 units toured (2 D) for 3 of 13 resident rooms (Resident #11, #13 and #14). This deficient practice was evidenced by the following: On 09/08/23 at 12:38 PM, during the initial tour of unit 2 D, the surveyors observed a brown, cloth recliner chair in Resident #13's room. The recliner had multiple areas of dark brown and circular stains on the arms, back rest, seat, and leg rest. There was an unused adult brief on the seat of the chair. Resident #13 was not in the room at the time of the observation. On 09/08/23 at 12:40 PM, in the presence of the surveyors, the Registered Nurse/Unit Manager (RN/UM) stated that Resident #13's recliner chair should not be that way. She further stated that the chair should be kept clean for infection control and dignity purposes. When the surveyors asked if she would sit in the recliner chair, the RN/UM stated no she would not. The RN/UM stated she was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REFER TO F610 REFER TO F609 Based on observation, interview, and record review, it was identified that the facility failed to report to the New Jersey Department of Health (NJDOH) and follow facility policy and procedures for reporting: a.) an unwitnessed event which resulted in a major injury for Resident #75, b.) an allegation and investigation of a resident to resident altercation, for Residents #27 and #228, c.) an allegation of abuse made by a resident representative for Resident #99, d.) an injury of unknown origin for Resident #99, and e.) an observed incident and investigation in which serious bodily injury occurred to Resident #191. The deficient practice was identified for five (5) of six (6) residents reviewed for alleged violations, (Resident #27, #75, #99, #191, and #228) and was evidenced by the following: 1. On 9/08/22 at 11:28 AM, the surveyor interviewed the responsible party (RP) for Resident #75 in the presence of a second surveyor. The RP informed the surveyors that Resident #75 sustained a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REFER to 609 Based on interview, observation, and record review, it was determined that facility failed to conduct a timely and through investigation, as well as, follow their own facility policy on Abuse Investigation and Reporting was consistently implemented for five (5) of six (6) residents (Resident #27, #75, #99, #102 and #228) reviewed for alleged violation investigations. This deficient practice was evidenced by the following: 1. On [DATE] at 11:28 AM, the surveyor interviewed the responsible party (RP) for Resident #75 in the presence of a second surveyor. The RP informed the surveyors that Resident #75 sustained a right hip fracture which required surgery. The RP stated that this occurred the day after Resident #75 had an incident whereby his/her finger got caught in the bed frame which Emergency Services (ES) were required to release by cutting the metal bed frame. The RP stated that Resident #75 was sent to the hospital for evaluation of the finger and that the resident complained of pain the next…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to accurately assess and properly code residents' status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 7 of 39 residents (Residents #13, #69, #102, #106, #177, #198 and #206) reviewed under Section C for cognition. This deficient practice was evidenced by the following: According to the CMS's (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual dated October 2019 Section C: Cognitive Patterns included Coding Tips .If the resident interview was not conducted within the look-back period (preferably the day before or the day of) the ARD (Assessment Reference Date), item C 0100 must be coded 1, Yes, and the standard no information code (a dash -) entered in the resident interview items. 1. During an observation on 8/31/22 at 10:54 AM by the surveyor, the Certified Nursing Aide (CNA) was inside the resident's room while providing morning care to the resident.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to: a.) follow the Physician's Order (PO) for the use of oxygen equipment b.) appropriately store portable oxygen tank to the back of resident wheelchair and c.) store respiratory equipment in a way to prevent the spread of infection. This deficient practice was identified for three of three residents' reviewed for respiratory care, (Resident #111, #159 and #191) and was evidenced by the following: The surveyor observed Resident #111. 1. On 9/01/22 at 11:32 AM, the surveyor observed the resident sitting in their high back wheelchair in their room watching TV. The surveyor observed an Oxygen (O2) concentrator in Resident #111's room next to Resident #111's bed. The O2 concentrator was running and set at two (2) Liters and Resident #111 was wearing their nasal cannula. The nasal cannula and humidification bottle were not labeled and dated. The surveyor also observed a portable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a.) medications that were ordered by the physician were available for administration during the months of April, May, and July 2022 for one (1) of 18 residents, (Resident #99) reviewed for medication management, b.) medications were observed as accurately and timely administered to one (1) of seven (7) residents, (Resident #121) reviewed for medication administration, and c.) a treatment medication was accurately administered and properly stored for one (1) of two (2) residents, Resident #69, reviewed for treatment medications. The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, it was determined that the facility failed to document non-drug interventions that were attempted and the need for an as needed psychoactive medication (Ativan) to be administered according to documented behaviors from April, May, June and July. The deficient practice was identified for one (1) of five (5) residents (Resident #101) reviewed for unnecessary medications, and was evidenced by the following: On 9/1/22 at 11:24 AM, the surveyor observed Resident #101 in a wheelchair in the Day Room. The resident waved the surveyor over to him/her. The resident stated that he/she wanted to get up and would then be able to walk out of the room. At that time, a Certified Nursing Aide (CNA) came over to the resident and asked if the resident would like to be taken somewhere else. On 9/1/22 at 11:26 AM, the CNA stated that the resident was confused and unable to stand on their own and often asked to be taken home. The CNA added that the resident had a behavior of yelling and does get anxious but was able to redirect the resident. On 9/2/22 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 2 of 6 units, (Unit 1 D and 2 A) and was evidenced by the following: 1. On the 1 D unit the surveyor observed the following: - On 9/9/22 at 10:53 AM, the surveyor observed on 1 D unit hallway (that covered both the high and low side), black colored stains on the floor and on the walls. - On 9/9/22 at 11:00 AM, the surveyor observed missing wall tiles in multiple areas of the 1-D hallway. - On 9/9/22 at 11:15 AM, the surveyor observed the unit D shower area (the only available shower room on 1-D) and observed the shower head on the shower stall floor. - On 9/9/22 at 11:15 AM, the surveyor observed a large dark stain on the tile floor of the 1-D shower stall. - On 09/09/22 at 11:17 AM, the surveyor observed the ceiling of the main shower room with rust marks and chipped paint that was right above where the residents' shower. - On 09/09/22 at 11:20 AM, the surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to provide information and educate residents on the Grievance process. This deficient practice was identified for 5 of 5 residents (Residents #44, #51, #67, #150, and #15) interviewed for the grievance process at the Resident Council meeting conducted on 9/15/22 at 10:30 AM and was evidenced by the following: On 9/15/22 at 10:40 AM, during the resident council meeting with five alert and oriented residents, the surveyor asked the residents if they were aware of what a grievance was and how to file a grievance with the facility if necessary. Five of the five residents present during the meeting told the surveyor they did not know the definition of a grievance or how to file a grievance. When the surveyor reviewed the resident council meeting minutes for June, July, and August 2022, prior to having the resident council meeting, the facility did not provide information regarding grievances. On 9/15/22 at 3 PM, the surveyor reviewed the Resident admission Packet which did not contain any information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed a.) to implement a comprehensive person-centered care plan intervention with regard to communication and b.) to develop a comprehensive person-centered care plan to address a behavior. The deficient practice was identified for 2 of 39 residents reviewed for care plans, (Residents #102 and #150), and evidenced by the following: 1. On 8/31/22 at 11:02 AM, the surveyor observed Resident#102 laying on the bed with the responsible party (RP) at the bedside. The RP stated that Resident#102 was cognitively intact, unable to speak appropriately but able to utilize the personal computer for communication. The RP further stated that he/she had a concern that the 11-7 staff think Resident#102 was cognitively impaired because Resident#102 was unable to talk properly due to ALS (Amyotrophic lateral sclerosis is a rare neurological disease that primarily affects the nerve cells responsible for controlling voluntary muscle movement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to update and revise an Interdisciplinary Comprehensive Care Plan (IDCCP) to include interventions for 1 of 11 residents, (Resident #121), reviewed for accidents. This deficient practice was evidenced by the following: On 9/13/22 at 11:10 AM, the surveyor observed Resident #121 who was alert, oriented, and seated in a wheelchair watching television. The surveyor reviewed the medical record for Resident #121. The admission Record reflected that Resident #121 was admitted to the facility with diagnoses that included but not limited to schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), bi-Polar illness (condition of mood swing from depressive lows to manic highs), major depressive disorder (long term loss of pleasure and interest) and anxiety disorder (disorder of feeling worried and fear). A review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 6/30/22, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review, it was determined that the facility failed to accurately transcribe a physician's order for a wound treatment to a stage 4 sacral pressure ulcer onto the Treatment Administration Record (TAR) for 1 of 4 residents (Resident #181) reviewed for wound care. The deficient practice was evidenced by the following: On 9/09/22 at 11:13 AM, the surveyor observed Resident #181 lying in bed with head of bed elevated and bed covers on and up to Resident #181's waist. Resident#181 was awake and watching television. A review of Resident #181's Electronic Medical Record (EMR) indicated that Resident #181 was admitted to the facility with a diagnosis that included, but not limited to, multiple sclerosis (a disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged. This damage can result in decreased vision, muscle weakness, and trouble with sensation and coordination.), peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to limbs), neuromuscular dysfunction of bladder (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 2 of 39 residents, (Resident #159 and Resident #177), and was evidenced by the following: 1. On 9/13/22 at 11:00 AM, the surveyor reviewed Resident #159 physician progress notes in the electronic medical record (EMR). In review of the physician notes the surveyor noted that all the resident's progress notes were written by an Advanced Practice Nurse (APN). The surveyor could not locate any notes written by the attending physician within the medical record. The surveyor then asked the Director of Nursing (DON) to provide all the resident's physician progress notes for July and August. The surveyor reviewed the admission Minimum Data Set (MDS), an assessment tool dated 7/13/22. Medical diagnoses included cancer, chronic obstructive pulmonary disease (COPD, a condition involving constrictions of the airways and difficulty or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to: a.) ensure that appropriate hand hygiene was performed by 2 of 13 staff observed during dining and wound care observation, and b.) disinfect the table for 1 of 2 staff observed for wound treatment in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for infection control and facility policies. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included, When to Perform Hand Hygiene? Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient .Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal . 1. On 9/9/22 at 12:29 PM, the surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.